Comparative study of safety and efficacy of electrocautery blade with

Kalawar et.al. Comparative study of safety Health Renaissance 2015;13(2): 43-49

Original Article

Comparative study of safety and efficacy of electrocautery blade with cold scalpel blade for skin opening during fixation of fracture of forearm bone with plate and screws RP Shah Kalawar, GP Khanal, P Chaudhary, R Rijal, R Maharjan, SR Paneru, B Pokharel Department of Orthopaedics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Abstract Background: Skin incisions have usually been made using a scalpel. Electrocautery, a more recent alternative, is thought to increase the risk of infection, impair healing and decrease cosmesis. Recent studies suggest that electrocautery may offer potential advantages with respect to blood loss, incision time and postoperative pain. Objective: The aim of this study was to compare the efficacy and safety of electrocautery incisions versus conventional scalpel incisions in orthopedic surgeries using internal implants. Method: The study was conducted as a prospective one in a tertiary care center in the Department of Orthopaedics, BPKIHS, Dharan, Nepal. Patients with closed fracture of the forearm bones admitted for surgery from April 2014 to September 2014 was included in the study. Each incision was divided into two halves, proximal half to be opened by steel scalpel blades and the distal half to be opened by an electrocautery blade. Proximal half and distal half of incision were compared on operating day and on days 2, 14 and again on 6 weeks and 3 month. Result: A total of 60 patients were enrolled in the study. Forearm skin incisions using electrocautery were significantly quicker than scalpel incisions (p0.05). Conclusion: There is no difference in healing of two halves of skin incision made by electrocautery and scalpel in orthopedic surgeries using internal implants. Key words: Electrocautery, skin incision, scalpel Introduction The

art

of

improved performing

surgeries

have

in

development

recent of

years

various

with

the

electrosurgical

devices assisting surgeons in performing Address for correspondence Rosan Shah Kalawar Department of Orthopaedics B.P. Koirala Institute of Health Sciences, Dharan Email: [email protected]

safer surgeries with better outcomes. Skin incision has traditionally been made with a standard scalpel blade with good primary 43


healing end results of the wound. The

•

Open fractures,

electrocautery has been used safely in

•

Previous history of hypertrophic or

performing

deeper

dissections.

Use

of

keloid scarring,

electrocautery in skin incision has been

•

Patients

suffering

from

discouraged in the past for the fear of

immunosuppressive

cutaneous scarring, wound dehiscence, and

wound healing problems,

infections particularly in orthopedic surgeries

•

chronic

disorders

or

Patients on long-term medications,

using internal implants.

which interferes with wound healing,

Recently, use of electrocautery has been

such as corticosteroids, anticancer

shown

drugs, or colchicines for gout.

to

offer

many

advantages

1-6

including time, safety and healing, yet still it is being debated. Therefore the present study

The patients were given numerical codes in

aimed

an

sequence. All surgeries were performed

electrocautery blade can be used safely for

under general/regional anesthesia with use of

skin incisions in limb surgeries.

tourniquets. The incision site was marked.

to

determine

whether

Each incision was then divided into two Methods

halves, proximal half to be opened by steel

The study was conducted as a prospective

scalpel blades and the distal half to be

one in a tertiary care center in the department

opened by an electrocautery blade [figure

of orthopaedics, BPKIHS, Dharan, Nepal.

1a]. The electrocautery unit was set on

Patients with closed fracture of the forearm

cutting pure mode, at a power of 5 W and

bones admitted for surgery from April 2014 to

using a 390-kHz sinusoid waveform during

September 2014 was included into the study.

the procedure.

The operating theatre records of 2013

The incision depth included the epidermis,

showed that the number of cases of forearm

dermis, and the superficial part of the

bones fracture operated from 1st April to 30th

subcutaneous layer. During electrocautery

September was 66. Arbitrarily it was decided

incision, only the tip of the blade was allowed

to take 60 of cases. Ethical clearance was

to come in contact with the proposed incision

obtained before the study from Institute

line and care was taken not to touch the skin

Ethical Review Board and informed consent

edges with the sides of the electrocautery

was taken from each patient involved in the

blade at any time by applying mild traction on

study. The following patients were excluded

either sides of the skin incision as the cutting

from study:

proceeded. 44


The floor nurse noted the time taken to

On completing total skin incision, the wound

complete the incision on each side separately

edges were inspected for any physical

using a stop clock. The length of each half of

differences between the parts performed by

the incision was recorded. The speed of skin

the electrocautery and cold scalpel [Figure

incision was calculated in mm/s from the start

1b]. The incision wound with scalpel and

of incision until completion of the incision,

electrocautery was inspected in each case

including hemostasis. The speed of incision

immediately after completing the skin incision

was

in

with respect to color, viability, presence of

millimeters by time in seconds for each half

charring effect, and dermal peeling by naked

separately. The time calculated for incision

eye examination.

calculated

by

dividing

length

did not include deep fascia or periosteum opening.

Figure 1a: Skin incision marked and divided into proximal half to be opened by scalpel (S) and distal half to be opened by Electrocautery; 1b: Macroscopic appearance of the wound on completing skin Deeper dissection was continued as usual

after incision; cosmetic appearance of the

and fractures was fixed with a 3.5 mm low-

scar as good, poor, contracted; and formation

contact dynamic compression plate in each

of keloids and wound complications.

case. The wound was closed in layers using nylon or staples for the skin. The fascia was

Results

not closed to decrease the chance of

Sixty incisions were performed using a cold

compartment syndrome if any. The wound

scalpel and electrocautery blade in open

was inspected on postoperative days 2, 14

reduction and internal fixation of the fracture

and at 6-weeks post-operative follow-up. The

of the shaft of the radius and/or ulna using a

variables evaluated in this study was time

low-contact dynamic compression plate.

taken for incision; differences with respect to

The speed of incision when a cold scalpel

physical inspection of the wound edges soon

was used ranged between 0.65 mm/s and 2.1 45


mm/s, with an average of 1.0 mm/s. The

cold scalpel and electrocautery incisions.

speed of incision with electrocautery blade

Postoperative inspection on days 2 and 14

was between 1.2 mm/s and 2.9 mm/s, with an

also did not have any differences in the

average of 1.8 mm/s. The average time taken

physical character of the wound [Figure 2a].

by electrocautery for performing a 10 cm skin

Healing of skin wound incised with cold

incision was 1 min against 2 min by cold

scalpel and electrocautery at the end of 6

scalpel.

The time taken for incision with

weeks and 3 months were the same [Figure

electrocautery was much lower in comparison

2b]. There were no differences in scar

with the cold scalpel.

tenderness on either half of the incision made

There were no macroscopic differences with

by cold scalpel and electrocautery at 3

respect

months follow up.

to

color,

viability,

presence

of

charring effect, and dermal peeling between

Figure 2a: Macroscopic appearance of the wound on 2nd week follow up and 2b: on 6 month follow up.

Because of the tourniquet application, blood

or electrocautery incision in 3 month follow

loss with these two methods of incision could

up.

not be evaluated. Two

(3.3%)

cases

of

superficial

Discussion

stitch

abscess were found involving the full length

Surgical electrocautery has increasingly been

of the skin incision, which was effectively

used for tissue dissection, being haemostatic

managed

and convenient, since beginning of the 20th

with

antibiotics

and

regular

dressings.

century when it was first introduced7-9.

There was no evidence of scar tenderness,

Surgeons, however, continue to be reluctant

hypertrophy, or keloid formation of the scar,

when it comes to the use of electrocautery for

or wound dehiscence either with cold scalpel

making an incision of skin9,10,11 because 46


previous studies has shown that the use of

fixation of the fracture of the shaft of the

electrocautery causes devitalization of tissue

radius and/or ulna using a low-contact

within the wound which consequently lead to

dynamic compression plate. Blood loss could

wound infection, delayed wound healing and

not be compared due to use of tourniquet.

excessive

scarring

9,10,12,13

.

Despite

The

this

fear

of

tissue

injury

and

wound

evidence in these randomized clinical trials in

complication in electrocautery incision was

support of electrocautery use in making skin

first unfolded when this technique was used

incisions, many surgeons in many centers

by Peterson16 in reconstructive and cosmetic

including our centre still are reluctant to use

faciomaxillary

electrocautery in making skin incisions

10,11

.

Tobin17

surgery,

in

blepheroplasty, with minimum scarring and

So this study was aimed at investigating this

excellent results.

alternative

with

Kearns et al12 who compared electrosurgical

comparison to the scalpel incision with

and scalpel methods in hundred patients

regards

undergoing elective midline incision have

to

method

of

advantages,

incision like

time

and

bleeding, as well as alleged complication like

found

wound infection.

significant advantages over scalpel incision

There are conflicting results

that

the

diathermy

incision

has

based on incision time, blood loss, early

in human

studies. It has been reported in Soballe et al14

postoperative

pain

study that electric coagulation increases the

requirements.

There

incidence of indurated margins, infections,

difference in terms of wound complications,

and

including wound infection, as reported by the

weakness

of

the

wound

cut

in

comparison with the knife. Conversely, Groot et

al15

reported

that

use

of

and was

no

analgesia significant

present study.

surgical

The present study showed no statistically

electrocautery to create surgical wounds in

significant

patients undergoing abdominal or thoracic

postoperative

operations carries a wound infection rate

postoperative hospital stay which is in

similar to that of scalpel.

consistent with other trials9,12. On the basis of

Our present study shows electrocautery

this study, it is suggested that skin may be

incision is better than scalpel incision in terms

safely incised using electrocautery in limb

of time taken for incision, and no significant

surgery involving fixation of bones using

difference in terms of wound healing, post

internal implants.

operative complication rate and in length of hospital stay in open reduction and internal 47

differences

in

the

complications

rate

of and


Conclusion

blind, randomized, clinical trial. World J

We conclude that skin may be safely and

Surg 2009; 33:1594-9. 6.

rapidly incised using electrocautery in limb

Chalya PL, Mchembe MD, Mabula JB,

surgery involving fixation of bones using

Gilyoma JM. Diathermy versus Scalpel

internal implants with as good wound healing

incision in elective midline laparotomy:

characteristics as that of with cold scalpel.

A prospective randomized controlled clinical

study.

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